rekam medik pdf
TRANSCRIPT
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REKAM MEDIK
By : Dr. Edy Ramdhani
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IDENTITAS PASIEN
NAMA.
UMUR.
JENIS KELAMIN.STATUS PERKAWINAN.
ALAMAT.
PEKERJAAN.
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ANAMNESA
KELUHAN UTAMA
KELUHAN KENAPA
PASIEN DATANG
BEROBAT.
CARI SEBANYAK-
BANYAKNYA
INFORMASI YANG
BERHUBUNGANDENGAN KELUHAN
UTAMA.
WAKTU, SIFAT,
FAKTOR YANG
MEMPERBERAT.
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………………………………………….ANAMNESA
KELUHAN
TAMBAHAN.
KELUHAN YANG
MENYERTAIKELUHAN UTAMA.
CARI SEBANYAK-
BANYAKNYA
INFORMASI YANG
BERHUBUNGANDENGAN KELUHAN
TAMBAHAN.
WAKTU, SIFAT,
FAKTOR YANG
MEMPERBERAT.
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………………………………………….ANAMNESA
RIWAYAT PENGOBATAN.
OBAT APA SAJA YANG
SUDAH DIMAKAN OLEH
PASIEN. DENGAN
MENANYAKAN NAMAOBAT, WARNA, BENTUK.
RIWAYAT ALERGI (OBAT
ATAU MAKANAN).
RIWAYAT PENYAKIT
TERDAHULU.
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VITAL SIGN
KEADAAN UMUM.
KESADARAN.
TEKANAN DARAH.
FREKUENSI NADI.
FREKUENSI NAFAS.
TEMPERATUR.
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PEMERIKSAAN FISIK
DARI UJUNG RAMBUT SAMPAI UJUNG KAKI.
KEPALA :
RAMBUT : WARNA, MUDAH DICABUT
ATAU TIDAK. MATA : KELOPAK MATA, KONJUNGTIVA,
SKLERA, PUPIL, REFLEKS CAHAYA.
HIDUNG : SEPTUM NASI, SEKRET, POLIP.
TELINGA : UKURAN, CAIRAN, MEMBRAN IMPANI.
PADA ANAK-ANAK : UUB
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MATA
KONJUNGTIVITIS UVEITIS
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REFLEKS PUPIL
Kecepatan refleks langsung & tdk langsung.
Ukuran.
Bentuk.
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REFLEKS PUPIL
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Lesi N II (Optikus)
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Lesi N. III (Okulomotorius)
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………………………………PEMERIKSAAN FISIK
LEHER : TIROID, JVP, KELENJAR GETAH BENING
(UKURAN, KONSISTENSI, MOBILE,
PERMUKAAN, NYERI).
THORAK :PARU :
I : SIMETRIS, KETERTINGGALAN BERNAFAS.
P : STEM PREMITUS TAKTIL.
P : SONOR, REDUP, HIPERSONOR.
A : VESIKULER, BRONKIAL, RONKHI, AMPORIK.
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Keterangan Cairan Udara
I Jejas, Tertinggal bernapas Jejas, Tertinggal bernapas
Deviasi Trakea, JPV
meningkat
P VP Melemah VP Melemah
P Redup Hipersonor
A Vesikuler Melemah/ Tdk
ada suara napas
Vesikuler Melemah/ Tdk
ada suara napas
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THORAK
SPIDER NIVE EMPISEMA SUBKUTAN
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………………………………PEMERIKSAAN FISIK
JANTUNG :
I : IKTUS.
P : IKTUS.
A : BUNYI MASING2 KATUP JANTUNG.
P : BATAS JANTUNG.
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………………………………PEMERIKSAAN FISIK
ABDOMEN :
I : CEMBUNG, DS, DC.
A : BU NORMAL, MELEMAH, MENINGKAT,
METALIC SOUND, BARBORYGNI SOUND. P : NYERI TEKAN, NYERI LEPAS, DEPANS
MUSKULER, MASSA (UKURAN,
KONSISTENSI, PERMUKAAN, NYERI). P : TYMPANI, HIPERTYMPANI, NYERI KETOK
CVA.
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ABDOMEN
DISTENSI DUMCOUNTUR
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INVAGINASI
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RETENSIO URINE
SEBELUM KATETER SESUDAH KATETER
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………………………………PEMERIKSAAN FISIK
GENITALIA :
PENIS : OUE, URETRA.
SCROTUM : TANDA RADANG.
TESTIS : UKURAN, KONSISTENSI,
NODUL, NYERI TEKAN.
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………………………………PEMERIKSAAN FISIK
RECTAL TOUCHER : SPINGTER ANI,
MUKOSA, NYERI, MASSA, AMPULA.
PROSTAT :
KONSISITENSI, PERMUKAAN, NODUL,
NYERI TEKAN, POOL ATAS.
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………………………………PEMERIKSAAN FISIK
EKTRIMITAS.
REFLEKS, KEKUATAN OTOT.
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PEMERIKSAAN PENUNJANG
HARUS SESUAI DENGAN INDIKASI.
DARAH (DARAH LENGKAP, KIMIA
DARAH).
FESES.
URIN.
RADIOLOGI.
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